Lumbar diskogenic pain, provocation diskography, and imaging correlates

Diskogenic pain refers to pain mediated by the intrinsic innervation of the intervertebral disk. It is experienced as pain centered at the symptomatic spine segment (axial pain) without radicular features or radiculopathy. There is no pathoanatomic gold standard; histologic examination cannot identify a painful disk. The current reference standard for diskogenic pain is provocation diskography. This article reviews diskogenic pain, the history of provocation diskography, and its current use in the diagnosis of lumbar diskogenic pain. The extensive literature describing imaging features which may predict a positive diskogram, and allow non-invasive diagnosis of diskogenic pain, is examined.     

Magnetic resonance imaging-guided diskography and diagnostic lumbar 0.23T MRI: an assessment study

Purpose: To describe the in vivo appearance of magnetic resonance imaging (MRI) diskograms of normal and degenerated lumbar intervertebral disks, and to evaluate the differences in imaging findings between sequential diagnostic MRI and MRI diskography.

Material and Methods: Nine consecutive patients underwent MRI-guided diskography in order to determine possible pain provocation during puncture and contrast medium injection. All patients had preceding clinical suspicion of lumbar diskogenic pain and findings of lumbar disk degeneration in diagnostic (MRI, computed tomography (CT), plain radiography). A 0.23T open MRI scanner with interventional tools was used for imaging and instrument guidance. On all patients, a complementary diagnostic MRI study of the lumbar spine before and after the MRI-guided disk injection was performed, and subsequent axial MRI diskograms were obtained.

Results: A total of 25 disk punctures were initialized, and 25 MRI diskograms were obtained and their expression described. There was a correlation between the degenerative disk findings visualized by diagnostic MRI and MRI diskograms.

Conclusion: The use of gadolinium contrast media in MRI-guided diskography enables the evaluation of MRI diskograms. Our results suggest that MRI-guided diskography can be used to substitute conventional diskography or CT-diskography and as an augmenting method to assess diagnostic information upon degenerative processes of the lumbar spine.     

Comparison of MR and diskography in detecting radial tears of the anulus: a postmortem study

Radial tears of the anulus fibrosus, which anatomic studies suggest are a primary event in disk degeneration, can be detected by diskography or MR imaging. We compared the sensitivity of MR and diskography in the detection of anular tears. MR, diskography, and cryomicrotomy anatomic sectioning were performed in eight cadaver lumbar spines. Diskography demonstrated 15 radial tears in 36 intervertebral disks. MR demonstrated 10 of the 15, a sensitivity of 67%. MR (T2-weighted images) in each of the diskographically normal disks showed the high signal intensity characteristic of normal disks. Thirteen of 15 disks from which contrast medium extravasated at diskography had diminished signal intensity in MR images. We conclude that although MR may demonstrate some radial tears of the anulus, and associated changes in the disk, it cannot be used as effectively as diskography to visualize a radial tear.     

Axial rotation of the lumbar spinal motion segments correlated with concordant pain on discography: a preliminary study

OBJECTIVE: One possible cause of back pain in patients with intervertebral disk degeneration is decreased stability of the motion segment. Axial rotations between lumbar spinal vertebrae can be measured noninvasively with CT. We tested the hypothesis that larger axial rotations are found in motion segments with disks that test positive for concordant pain, which is considered by some investigators to be a reasonable, accurate predictor of spinal instability. SUBJECTS AND METHODS: Between October 2002 and March 2004, all patients undergoing discography were evaluated for inclusion in the study, with the approval of the institutional review board. All patients in whom concordant pain was detected at discography were enrolled in the study. The patients were placed supine in the CT scanner on a table that rotated the pelvis 8 degrees clockwise and then counterclockwise with respect to the thorax. CT images were obtained with the patient in the two positions of rotation. An automated program calculated the amount of rotation between each lumbar vertebra as a result of the table rotations. Rotations were stratified by disk level and by disk classification (concordant pain, nonconcordant pain, no significant pain). RESULTS: We recorded the axial rotations of 94 disks in 16 consecutive patients (10 women, six men; age range, 26-53 years) after two disks were excluded because of a previous fusion. There were 68 normal disks by MRI and discography, six disks with nonconcordant pain, and 20 disks with concordant pain. Rotation averaged 0.6 degrees for the normal disks, 1.4 degrees for disks with nonconcordant pain, and 1.8 degrees for disks with concordant pain. The differences were significant (analysis of variance, p < 0.001). Disks at L3-L4 with concordant pain rotated on average 1.2 degrees , whereas disks classified as normal or nonconcordant pain rotated on average 0.7 degrees (significant at p = 0.005). Disks at L4-L5 with concordant pain rotated on average 1.9 degrees , and those without concordant pain rotated on average 1.4 degrees (significant at p = 0.05). Disks with concordant pain at L5-S1 had an average rotation of 2.2 degrees , whereas disks without concordant pain had an average rotation of 1.5 degrees (marginally significant difference at p = 0.07). CONCLUSION: Concordant pain at discography predicts increased axial rotation at a lumbar disk level.     

Observer variation in MRI evaluation of patients suspected of lumbar disk herniation

OBJECTIVE: Our objective was to assess observer variation in MRI evaluation in patients suspected of lumbar disk herniation. SUBJECTS AND METHODS: Two experienced neuroradiologists independently evaluated 59 consecutive patients with lumbosacral radicular pain. Per patient, three levels (L3-L4 through L5-S1) and the accompanying roots were evaluated on both sides. For each segment, the presence of a bulging disk or a herniation and compression of the root was reported. Images were interpreted twice: once before and once after disclosure of clinical information. Interobserver agreement was expressed as unweighted kappa values. RESULTS: Without clinical information, interobserver agreement for the presence of herniation or bulging disk was moderate (full agreement, 84%; kappa = 0.63; 95% confidence interval [CI], 0.53-0.72). Of a total of 352 segments evaluated, there was disagreement on 58 segments (17%): bulging disk versus no defect in 26 (7.4%), bulging disk versus herniation in five (1.4%), and hernia versus no defect in 27 (7.7%). With clinical information, twice as many bulging disks were reported but no new herniations were detected. Agreement slightly decreased, but not significantly (full agreement, 77%; kappa = 0.59; 95% CI, 0.49-0.69; p = 0.12). CONCLUSION: On average, more than 50% of interobserver variation in MRI evaluation of patients with lumbosacral radicular pain is caused by disagreement on bulging disks. Knowledge of clinical information does not influence the detection of herniations but lowers the threshold for reporting bulging disks.     

Radiating pain to the lower extremities caused by lumbar disk rupture without spinal nerve root involvement.

PURPOSETo locate the origin of the pain during lumbar diskography by means of a limited intradiskal injection of a local anesthetic.METHODSLumbar diskography by the direct central posterior approach was performed in 235 consecutive patients. In 17 patients, severe and persistent low back pain, with unilateral or bilateral radiation to the lower extremities, was provoked by contrast injection into only one disk. One milliliter of 1% lidocaine was then slowly injected in the center of these disks.RESULTSA 75% to 100% reduction of the low back pain was experienced by 13 patients, and a 75% to 100% reduction of the radiating pain was experienced by 16 patients within 60 seconds after the intradiskal injection of lidocaine. Radiographs demonstrated radial tears through the entire annulus thickness in 16 of 17 disks.CONCLUSIONOur results suggest that, in some patients with low back pain and unilateral or bilateral radiation to the lower extremities, the pain arises from within the disk. In these cases, pain radiating to the lower limb seems to be a referred type and seems unrelated to direct nerve root compression or irritation by a disk fragment in the epidural space.     

前入路经腹L5／S1椎间盘髓核摘除术的穿刺技术

目的 探讨前入路经腹L5／S1椎间盘髓核摘除术（TALD）的穿刺技术和方法。方法 尸体标本2具,解剖暴露L5／S1椎间盘前缘,用细针行多角度穿刺,探讨L5／S1椎间盘前路穿刺的进针方向。腰骶椎骨标本30套,摄片观察L5／S1椎间盘穿刺的影像标志。钡餐检查时,随机选取200例被检者,观测各骨性标志的显示率。TALD治疗L5／S1椎间盘脱出68例进行回顾。结果 TALD关键的步骤是穿刺针与腰骶间隙平行刺入椎间盘,必须确定皮肤进针点和椎间盘前缘进针点,椎间盘邻近的5个骨性标志对穿刺定位有重要帮助。结论 正确的穿刺方法对TALD的开展有重要意义。     

腰椎间盘退变患者的髓核ADC值与解剖位置关系的初步研究

目的:应用DWI探讨腰椎退行性变患者椎间盘髓核ADC值是否与椎间盘的解剖层面相关。方法:对72例腰椎间盘退变患者行腰椎MRI普通序列和DWI扫描,并测量L1~2至L5~S1椎间盘髓核的ADC值,分析椎间盘髓核平均ADC值与解剖层面之间的相关性。结果:L1~2至L5~S1椎间盘平均ADC值分别为(1.47±0.33)×10-3 mm2/s、(1.47±0.31)×10-3 mm2/s、(1.42±0.34)×10-3 mm2/s、(1.33±0.35)×10-3 mm2/s、(1.32±0.38)×10-3 mm2/s。从L1~2至L5~S1随着椎间盘位置的下移,ADC值有下降趋势。椎间盘的平均ADC值仅在L1~2与L4~5、L1~2与L5~S1、L2~3与L4~5、L2~3与L5~S1之间差异有统计学意义(P0.05)。结论:椎间盘髓核的ADC值能反映腰椎间盘退行性改变,且L4~5与L5~S1椎间盘ADC值较L1~2与L2~3低,差异有统计学意义。     

Nucleolysis and diskography — An experimental study on interaction of chymopapain and contrast medium

Summary A test was carried out on 11 young, full sized mongrels to determine whether there is an interaction between chymopapain and the contrast agents iotrolan and iopamidol. A total of 75 intervertebral disks were punctured: nucleolysis alone was performed on 20, diskography with iotrolan and subsequent nucleolysis on 20, and diskography with iopamidol and subsequent nucleolysis on 10. Diskography alone was performed 10 times with iotrolan and 5 times with iopamidol. Aqua dest. was given intradiskally 5 times, and puncture was carried out 5 times without the administration of any substance. Following puncture, x-rays of the lumbar vertebral column were taken laterally: daily for the first 10 days, then weekly. Disk space narrowing typical of nucleolysis with chymopapain was found among the disks that were nucleolyzed only to the same extent as among those that had undergone diskography previously. There was no evidence of narrowing of the other disk spaces which had been punctured but not treated with chymopapain. On some of the dogs, CT and MRI examinations were carried out. The CTs showed a homogenous hypodensity in all of the disks, in which chymopapain had been injected. The MRI revealed a signal loss in all ot the nucleolyzed disks. The results of short and long term follow up demonstrate that inhibition of chymopapain by iotrolan or iopamidol is not to be expected and therefore diskography prior to chemonucleolysis can be performed without danger of enzyme inactivation.     

Percutaneous tumor ablation: increased necrosis with combined radio-frequency ablation and intratumoral doxorubicin injection in a rat breast tumor model

PURPOSE: To investigate the predictive value of magnetic resonance (MR) imaging of abnormalities of the lumbar intervertebral disks, particularly with adjacent endplate changes, to predict symptomatic disk derangement, with discography as the standard. MATERIALS AND METHODS: Fifty patients aged 28-50 years with chronic low back pain and without radicular leg pain underwent prospective clinical examination and sagittal T1- and T2-weighted and transverse T2-weighted MR imaging. Subsequently, patients underwent lumbar discography with a pain provocation test (116 disks). MR images were evaluated for disk degeneration, a high-signal-intensity zone, and endplate abnormalities. Results of pain provocation at discography were rated independently of the image findings as concordant or as nonconcordant or painless. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated to assess the clinical relevance of MR abnormalities. RESULTS: Normal disks on MR images were generally not painful at provocative discography (NPV, 98%). Disk degeneration (sensitivity, 98%; specificity, 59%; PPV, 63%) and a high-signal-intensity zone (sensitivity, 27%; specificity, 85%; PPV, 56%) were not helpful in the identification of symptomatic disk derangement. When only moderate and severe type I and type II endplate abnormalities were considered abnormal, all injected disks caused concordant pain with provocation (sensitivity, 38%; specificity, 100%; PPV, 100%). CONCLUSION: Moderate and severe endplate abnormalities appear be useful in the prediction of painful disk derangement in patients with symptomatic low back pain.     

Intervertebral disk appearance correlated with stiffness of lumbar spinal motion segments.

BACKGROUND AND PURPOSE: Because it diminishes the stiffness of the intervertebral disk, disk degeneration results in abnormal motions of the spine. Therefore, disk degeneration associated with back pain may indicate spinal fusion. The purpose of this study was to correlate the MR appearance and stiffness of lumbar intervertebral disks. METHODS: Eighty-two lumbar spinal segments were imaged with MR. The intervertebral disks were classified as: 1) normal, 2) having transverse or concentric tears of the annulus fibrosus if MR imaging showed only these changes, 3) having radial tears of the annulus fibrosus if MR imaging showed high-intensity zones in the annulus fibrosus or reduced signal intensity in the disk characteristic of radial tears, or 4) having advanced degeneration if MR imaging showed markedly reduced height, large osteophytes, or both. The rotation occurring from the application of a 6.6-Newton-meter (Nm) moment of axial rotational torque was measured kinematically. Average stiffness, in Nm/degree, was calculated as the ratio of the torque to the rotation. RESULTS: Stiffness averaged 7.0 Nm/degree for the normal group; 1.9 Nm/degree for the disks with concentric or transverse tears; 1.7 Nm/degree for disks with radial tears; and 3.1 Nm/degree for disks with advanced degeneration. The differences were statistically significant. CONCLUSION: Concentric, transverse, and radial tears of the intervertebral disk indicate reduced stiffness of the intervertebral disk and increased motions for a unit of applied torque. The most severely reduced stiffness was found in disks with radial tears of the annulus fibrosus. With collapse of the disk space, stiffness increases.     

Measuring diffusion of solutes into intervertebral disks with MR imaging and paramagnetic contrast medium.

BACKGROUND AND PURPOSEExperimental studies have shown that solutes diffuse more slowly into degenerated intervertebral disks than into normal disks. A noninvasive clinical study of diffusion in intervertebral disks is not generally available. Our purpose was to evaluate contrast-enhanced MR images to study diffusion in normal and degenerated lumbar intervertebral disks.METHODSThe change in signal intensity (as a proportion of baseline signal intensity) was calculated in lumbar intervertebral disks on MR images obtained before and after injection of intravenous contrast medium in 15 patients with low back pain. The intervertebral disks were classified as normal or degenerated on the basis of the MR appearance. Postoperative disks and degenerative intervertebral disks with a "high-intensity zone" were excluded. The changes in signal intensity as a proportion of baseline signal intensity were compared in degenerated disks and normal disks and the differences tested for statistical significance.RESULTSAfter intravenous administration of a gadolinium complex, signal intensity in normal intervertebral disks increased an average of 36% of baseline. In intervertebral disks with signs of degeneration, it increased an average of 21% of baseline. The difference was significant.CONCLUSIONThe study shows that diffusion into normal human lumbar intervertebral disks can be evaluated with MR imaging combined with intravenous contrast medium. With suitable MR techniques, the relationship between diffusion and disk degeneration, and the effect of trauma, drugs, and nutrition on disk degeneration can be studied noninvasively.     

Lumbar intervertebral disk degeneration in elite competitive swimmers: a case control study

BACKGROUND: The majority of orthopaedic problems experienced by competitive swimmers are related to pain in the shoulder, low back, and knee. Three of 39 national swim team members were hampered in their performance due to lumbar disk herniation at an international competition in 2001. There has been no previous research into lumbar disk degeneration in elite competitive swimmers. HYPOTHESIS: Excessive competitive swimming activities accelerate lumbar disk degeneration. STUDY DESIGN: Case control study; Level of evidence, 3. METHODS: Fifty-six elite swimmers (high-load group, 35 men and 21 women; mean age, 19.6 years) and a control group of 38 university recreational level swimmers (low-load group, 24 men and 14 women; mean age, 21.1 years) were evaluated for lumbar disk degeneration using magnetic resonance imaging. We compared the prevalence of disk degeneration and the disk level between the 2 groups and further investigated the relationship among their symptoms, swimming styles, and disk degeneration. RESULTS: Thirty-eight (68%) elite swimmers and 11 (29%) controls had degenerated disks at various disk levels, and the prevalence was significantly greater in the elite swimmers (P = .0002). Comparison between the 2 groups of the prevalence of disk degeneration at each level revealed that the disk level of L5-S1 was significantly more frequently degenerated in the high-load group (P = .026). There was no significant relationship observed among the variables of low back pain symptoms, swimming strokes, and disk degeneration. CONCLUSION: Excessive competitive swimming activities might exaggerate lumbar intervertebral disk degeneration, especially in the L5-S1 intervertebral segment.     

Correlation of diffusion in lumbar intervertebral disks with occlusion of lumbar arteries: a study in adult volunteers.

PURPOSE: To evaluate the correlation of the diffusion values in lumbar intervertebral disks with lumbar artery status and the degree of disk degeneration. MATERIALS AND METHODS: Sagittal T2-weighted images of the lumbar spine were obtained in 37 asymptomatic volunteers aged 22-68 years. The apparent diffusion coefficient (ADC) of 98 lumbar intervertebral disks was determined, and two-dimensional time-of-flight magnetic resonance angiography was performed on the corresponding 98 lumbar artery pairs (total arteries = 196). The degree of disk degeneration and the status of lumbar arteries were evaluated independently by two radiologists. ADC calculations were performed on the basis of the average signal intensities of the selected region of interest in lumbar disks. The association between ADC values of disks, the disk degeneration, and the status of lumbar arteries of the same level were analyzed with analysis of covariance, and pairwise analysis between groups (Scheffé post hoc multiple comparison) was performed with statistical software. P values less than .01 were considered significant. RESULTS: The lumbar arterial status correlated strongly with the diffusion values of intervertebral disks, and the ADC values decreased with higher degrees of arterial narrowing. The correlation between disk degeneration and diffusion was not significant. Eight severely degenerated disks with normal lumbar artery status and diffusion values were found. CONCLUSION: Impaired flow in lumbar arteries is significantly associated with decreased diffusion in lumbar disks and may play an important role in disk degeneration.     

Lumbar radiculopathy associated radicular schwannoma: A case report and literature review

Lumbar radiculopathy is a clinical condition defined by symptoms of pain, weakness, numbness, or tingling due to lumbar nerve root compression in levels L1-L4. Typically, it is characterized by a narrowing near the nerve root possibly caused by stenosis, bone osteophytes, disc herniation, and similar conditions. Reports of lumbar radiculopathy brought about by the presence of a radicular schwannoma are exceedingly rare. In this paper, we discuss the case of a 67-year-old female patient, presenting with complaints of low back pain, numbness, and antalgic gait for the past eight months. Her physical examination revealed motor and sensor neurological deficits affecting the left lower limb. The electromyoneurography evaluation showed neurogenic atrophy of the left radicular area, while the MRI revealed the presence of a giant, radicular schwannoma at L4-L5 level. This case report aims to underscore the clinical course and management of lumbar radiculopathy caused by a rare L4-L5 radicular schwannoma. Our patient had no significant risk factors or previous spinal pathology.     

Diskography: infectious complications from a series of 12,634 cases

BACKGROUND AND PURPOSE: Diskography is commonly performed to investigate pain of suspected diskogenic origin. Although uncommon, diskitis is a feared complication of this procedure. We reviewed the incidence of diskitis and other infectious complications following diskography in a large busy outpatient practice and discuss technical aspects that may contribute to infection prevention. METHODS: We reviewed the electronic records of all diskograms obtained at our institution during a 12.25-year period, looking for all cases of procedure-related infection. All diskograms had been obtained by skilled and experienced procedural radiologists in dedicated spine-injection suites with specialized technical staff. RESULTS: There were 12,634 examinations performed on 10,663 patients for a total of 37,135 disk levels. Of the disk levels, 5981 were cervical; 3083, thoracic; and 28,071, lumbar. Two cases of confirmed lumbar diskitis and no cases of either cervical or thoracic diskitis were seen in our series. No other infectious complications were found. The incidence of diskitis was 0.016% per examination and 0.0054% per disk level. CONCLUSION: In skilled and experienced hands using proper technique, diskography is a safe outpatient procedure with an extremely low incidence of diskitis and other procedure-related infections.     

Percutaneous laser disk decompression under CT and fluoroscopic guidance: indications, technique, and clinical experience.

The aim of percutaneous laser disk decompression (PLDD) is to vaporize a small portion of the nucleus pulposus of an intervertebral disk, thereby reducing the volume and pressure of a diseased disk. This minimally invasive technique can be performed in patients who need surgical intervention for disk herniation with leg pain. PLDD is usually performed under fluoroscopic guidance with or without diskoscopy. However, it can also be performed under dual computed tomographic (CT) and fluoroscopic guidance as an outpatient procedure. CT and fluoroscopic guidance increases the safety and accuracy of PLDD, with high precision of instrument guidance, direct visualization of nucleus pulposus vaporization, and reduced risk of complications. Of 119 patients with lumbar disk herniation treated with PLDD under CT and fluoroscopic guidance, 91 (76.5%) had a good or fair response. PLDD performed with CT and fluoroscopic guidance appears to be a safe and effective treatment for herniated intervertebral disks.     

Facettenblockade, peridurale und periradikuläre Schmerztherapie

More than 80% of vertebrogenic lumbar pain is unspecific and can only be attributed to a specific anatomic structure with difficulty. The pain can emanate from the intervertebral discs, intervertebral and sacroiliac (SI) joints, musculature, and ligaments. In a maximum of 7% of cases, the pain is radicular (4% due to intervertebral discs and 3% caused by stenoses). In 7-15% of cases, the pain's origin is located in the region of the vertebral joints and in up to 15% in the region of the SI joint. Although the overwhelming majority of pain has no clear structural cause, infiltrations of medications and nerve blockades are frequently employed. The efficacy of these procedures has however not been verified in controlled studies with the exception of epidural injection of corticosteroids for radicular pain. Epidural and epiradicular application of corticosteroids appear to be effective for radicular pain, at least on a short-term basis, although controlled studies have yielded controversial results. The difficulty lies partly in the exact placement at the affected root for applying the medication. This is hardly possible with a caudal injection, while with a lumbar peridural injection and periradicular injections it is only possible under X-ray control or even better CT guidance.